Online Program

Rural community care teams, shared care coordination, and improved community outcomes

Monday, November 4, 2013 : 2:30 p.m. - 2:50 p.m.

Pat Conway, PhD, LCSW, Essentia Institute of Rural Health, Essentia Health, Duluth, MN
Heidi Favet, Essentia Health, Ely, MN
This case study presents the development of the Ely Community Care Team (CCT), located in a geographically remote, rural region with limited resources. The CCT is creating a local approach to improve health outcomes and reduce unnecessary health care usage, adapting care management and interorganizational teaming for this rural community. Care coordination, one key strategy in the Accountable Care Act, holds promise for improving health, including behavioral health, outcomes while reducing costs. The presentation will describe development of the interdisciplinary team, including its successes and challenges, and the results of the evaluation of the pilot of the care coordination model. The evaluation, guided by community-based participatory research tenets, collected information through interviews and electronic surveys with team members, observation in the community, and electronic data collection from patients who participated in care management. Team members identified community needs, made recommendations for the development of care coordination, and described relationships between organizations participating in the CCT. Using social network analysis, characteristics of organizational relationships, patterns of referrals and sharing funding and data are described. Patient reported wellness outcomes (the SF-36 and the Patient Assessment of Chronic Illness Care) and changes in service usage, for instance, decreased emergency room use, are presented to demonstrate the impact of CCT on patients. The case study provides guidance for further implementation of the CCT; for the development of a care coordination model for potential implementation in other rural communities; and for further research regarding the impact of care coordination on health outcomes in rural communities.

Learning Areas:

Clinical medicine applied in public health
Conduct evaluation related to programs, research, and other areas of practice
Diversity and culture
Program planning
Provision of health care to the public
Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Identify the key components of the process of creating a successful community care team in a rural, remote community. Describe the use of social network analysis in assessing organizational relationships and measuring their change over time. Assess the value of using electronically collected, "patient reported outcomes" to measure wellness of community members who are recipients of care coordination overseen by the community care team.

Keyword(s): Community Collaboration, Wellness

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the evaluator for the Ely Community Care Team Project. I completed the research regarding the team, including the social network analysis, and of the pilot, where patient reported outcomes are being collected. I have conducted health-related research and evaluation for 32 years on topics such as rural health and behavioral health, violence prevention, and aging. I have presented results at APHA and other national and international conferences.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.